NC 4-H Youth Development Health History & Authorization Form

4-H Group / County: Year: (Must be updated each year) 4-H ers Name: Last Name First Name Middle Initial Birth Date / / Age as of Jan. 1 Gender: Female Male Email: Address: Street City State Zip Code Custodial Parent/Guardian Name: Phone: ( ) Second Parent/Guardian or Emergency Name: Address: Phone: ( ) If not available in an emergency, notify (Name): NC 4-H Youth Development Health History & Authorization Form Relationship: Phone: ( ) Health History The following information should be filled in by the parent/guardian, or adult. Update required annually. For residential camp attendance, health exam must be completed by an approved licensed medical personnel within 24 months of participation in the camp. The intent of this information is to provide NC 4-H health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to NC 4-H. Provide complete information so that the NC 4-H can be aware of your needs. MEDICATIONS Please list ALL medications, even over-the-counter or nonprescription drugs, including Tylenol, Pepto-Bismol, Benadryl, etc. that may be taken. If attending out of county events, bring enough medication to last the entire time you are away. Keep it in the original packaging/bottle that identifies the prescribing physician (if prescription drug), the name of medication, the dosage, and the frequency of administration. This person takes NO medications on a routine basis This person takes medications as follows: Med#1 Reason Dosage Time taken Med#2 Reason Dosage Time taken Med#3 Reason Dosage Time taken Med#4 Reason Dosage Time taken This person may take the following medications as needed: Aspirin Tylenol Ibuprofen Benadryl Pepto-Bismol Other Known allergies to foods, drugs, insect stings or bites, etc: Restrictions - The following restrictions apply to this individual: Dietary Vegetarian Vegan Other (describe) Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary): General Questions (Explain yes answers.) Has/does the participant: Yes No Yes No 1. Had any recent injury, illness or infectious disease? 13. Ever had high blood pressure? 2. Have a chronic or recurring illness/condition? 14. Ever been diagnosed with a heart murmur? 3. Ever been hospitalized? 15. Ever had back problems? 4. Ever had surgery? 16. Ever had joint problems? 5. Have frequent headaches? 17. Have any skin problems? 6. Ever had a head injury? 18. Have diabetes? 7. Ever been knocked unconscious? 19. Have asthma? 8. Wear glasses, contacts or protective eye wear? 20. Had mononucleosis in the past 12 months? 9. Ever had frequent ear infections? 21. Have problems sleepwalking? 10. Ever been dizzy/passed out during or after exercise? 22. Have a history of bed wetting? 11. Ever had seizures 23. Ever had an eating disorder? 12. Ever had chest pain during or after exercise? 1

Please explain yes answers, noting the number of the questions. Special medical concerns or conditions that event supervisors should know about, including contagious illnesses, epilepsy, asthma, diabetes, previous injuries to bones/joints, etc: Which of the following has the participant had? Measles Chicken pox German measles Mumps Hepatitis A Hepatitis B Hepatitis C TB Mantoux Test Result: Positive Date of last test Negative Use this space to provide any additional information about the participant s behavior and physical, emotional or mental health about which the NC 4-H should be made aware. Name of family physician: Phone: ( ) Address: Name of family dentist/orthodontist: Phone: ( ) Address: Insurance Information The 4-H program purchases accident insurance for youth participants for many sponsored events. This coverage is not a substitute for personal health insurance, and may not cover all accident or medical expenses. Therefore, medical providers may find it necessary to bill the family or your insurance company for medical services rendered. Please provide the following information: Health Insurance Company Health Insurance Policy # Company Address Company Telephone Number ( ) 2

Authorization Form Custody Release: You may be asked to produce photo ID at check-out. This is for your child s safety. Please be aware of this policy before picking up your child. I hereby give permission for my child,, to be allowed to leave the 4-H program after the activity. My child will be released into the custody of: (Names of Individuals authorized to pick up your child) If it is necessary for my child to leave before the end of the program due to illness, injury, or behavioral issues, and I cannot be reached, I hereby give permission for my child to be released into the custody of: (Emergency contact or other individual authorized to pick up your child) For 4-H Use Only: 4-H er picked up by: Staff Signature Parent/Guardian Authorization: This health history is correct and complete as far as I know. The person herein described has permission to engage in all 4-H activities except as noted. I hereby give permission to the NC 4-H to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to NC 4-H to arrange necessary related transportation for me/my child. The person herein described has permission to engage in all 4-H activities except as noted here: In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by NC 4-H to secure and administer treatment including hospitalization, for the person named above. This completed form may be photocopied for trips out of county. Signature of parent/guardian, or adult camper/staffer: Printed Name: Date: 3

Health Care Recommendations by Licensed Medical Personnel for 4-H Camp Participants Only I examined this individual on. BP Wt Ht In my opinion, the above applicant is is not able to participate in an active camp program. Restrictions/Recommendations: Treatment to be continued at camp or medications to be administered at camp (name, dosage, frequency) Additional information for health care staff at camp: Signature of Licensed Medical Personnel: Printed: Address: Phone: ( ) Street City State Zip Code Title: Date: Please give dates of immunizations for: (Immunization records may be attached to this form) Vaccine Mo/Yr Mo/Yr Mo/Yr Mo/Ry DTP TD (tetanus/diphtheria) Tetanus Polio MMR Or Measles Or Mumps Or Rubella Haemophilus influenzae Hepatitis B Varicella (chicken pox) Screening Record: For camp use only Meds received Updates/additions to Health History Current Health needs identified Screened by Date Time 4

4-H Enrollment Form Name of 4-H Group/Unit: Year: Member Name: First Middle Last Address: Phone:( ) Email: County: Gender*: q Male q Female Date of Birth: Grade: School Attending: If re-enrolling in 4-H, how many years have you been in 4-H: Do you live*: q Farm q City over 50,000 people (Choose only one) q Town under 10,000 people or rural non-farm q Suburbs of city over 50,000 people q City 10,000-50,000 people q Military installation: Do you have parent/guardian(s) active in the military? Yes No If yes, circle all that apply: Army Air Force Navy Marines Coast Guard National Guard(Air & Army) Reserves Ethnic group:* A. Choose One: q Hispanic or Latino q Non-Hispanic or Latino B. Choose all that apply: q White or Caucasian q Black or African-American q American Indian or Alaska Native q Asian q Native Hawaiian or other Pacific Islander q Other Parent or Guardian: First Middle Last Address: Phone: ( ) ( ) Area Code Daytime/Cell phone Area Code Home phone Email (if applicable) Additional Parent or Guardian: First Middle Last Address: Phone: ( ) ( ) Area Code Daytime/Cell phone Area Code Home phone Email (if applicable) 1. A parent or guardian should sign below whichever statements you wish to apply to the youth s involvement in 4-H programs. I agree to allow 4-H to take photographs/audio/video of my child for use in 4-H and other N.C. Cooperative Extension educational, promotional, and/or marketing materials. Neither individual addresses nor telephone numbers will be published within these materials. I do not wish for 4-H to take photographs/audio/video of my child for use in 4-H or N.C. Cooperative Extension educational, promotional or marketing purposes. 2. The enrolling youth is bound by the NC 4-H Code of Conduct and Disciplinary Procedure for 4-H events and activities. The youth should initial here if he/she has received and reviewed the NC 4-H Code of Conduct and Disciplinary Procedure for 4-H events and activities:. *This information is required for all federally assisted programs and is solely used for the purpose of determining compliance with Federal civil rights laws; your responses will not affect consideration of your application. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner. For office use only 4-H Membership # Date entered: Revised 10/21/13 Distributed in furtherance of the acts of Congress of May 8 and June 30, 1914. North Carolina State University and North Carolina A&T State University commit themselves to positive action to secure equal opportunity regardless of race, color, creed, national origin, religion, sex, age, or disability. In addition, the two Universities welcome all persons without regard to sexual orientation. North Carolina State University, North Carolina A&T State University, U.S. Department of Agriculture, and local governments cooperating.

LIABILITY WAIVER, ASSUMPTION OF THE RISK, PHOTO & MEDIA RELEASE, AND INDEMNIFICATION AGREEMENT In consideration for being allowed by NC State and its NC Cooperative Extension Service ( NC State ) to participate and use the facilities, services, and/or programs of the Camp (hereinafter Camp ) the undersigned custodial parent/guardian hereby agrees as follows: I do hereby affirm and acknowledge that my child is participating in the Camp for his/her own personal benefit, and have been fully informed of the inherent and potential hazards and risks to them associated with participation in sports, recreational, outdoor activities and any physical exertion required therein. I understand and acknowledge that the inherent dangers and physical risks involved in these activities are such that that no amount of care, caution, instruction or expertise can eliminate. These hazards and risks include, but are not limited to, loss or damage of personal property, mental or emotional distress, broken bones, strains, sprains, bruises, heart attacks, heat exhaustion, concussions, and other personal injuries, or even death, that could result from falling from heights, tripping due to uneven terrain, contact with other individuals, drowning, allergic reactions to foods, flora or insects, exposure to temperature extremes or inclement weather, sun hazards, equipment failure, hypothermia, and vehicle accidents while traveling to and from the activity site. I assume responsibility for all risks, known and unknown, involved to my child and their property in the aforementioned activities, and I voluntarily authorize my child s participation in reliance upon my own judgment and knowledge of my child s experience and capabilities. I understand that the determination of my child s ability to participate in the Camp should be made by my child s physician if necessary. I understand that I need the approval of a physician if I am uncertain as to his/her physical fitness for the rigors of this Camp. I understand that I may be required to seek approval from a physician if there is a health or safety question relative to my child s condition before being allowed to participate in the Camp. In addition, I give permission to any doctor, hospital, or other medical facility to release confidentially to the treating physician(s) for my child any information they may have concerning his/her medical condition and their professional contact with him/her for treatment purposes. I hereby grant my permission for such diagnostic, therapeutic, and operative procedures as deemed necessary for my child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance. I shall indemnify and hold harmless NC State, its trustees, officers, employees and agents from any liability, losses, costs, damages, claims or causes of action of any kind or nature whatsoever, and expenses, including attorney s fees, arising from or proximately caused by my child s participation in this Camp, including any travel. I further agree to accept and assume for myself, my assigns, executors, and heirs any and all such risks and losses that may occur. I have read the Camp s rules and regulations and hereby accept the regulations of the Camp described therein. I understand that the Camp has the authority to establish and enforce other regulations in addition to these. {N0015230.1}

I do hereby agree to allow my child to be photographed, audio or videotaped by NC State. I further agree that my child s image or likeness in photographs, videos, or audio may be used for educational or promotional purposes, including posting on the Internet. I agree that the use herein may be without compensation to me or my child. I hereby waive any right to inspect or approve the finished electronic, photograph, or printed matter that may be used in conjunction with them now or in the future. I am expressly releasing NC State, its agents, employees, licensees and assigns from any and all claims which I may have for invasion of my child s privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast or exhibition of such recordings. Check only if: I do not agree to photo/media use for any public release by NC State I further agree that this agreement shall be governed by and interpreted in accordance with the laws of the State of North Carolina. The terms of this agreement are severable such that if one or more provisions are declared illegal, void or unenforceable, the remainder of the provisions shall continue to be valid, enforceable, and binding upon the parties. I understand that this is a legal document which is binding on me, my heirs and assigns and on those who may claim by or through me. I am eighteen years of age or older, and have full capacity to enter into this agreement and do so voluntarily. I HAVE READ THIS AGREEMENT, I UNDERSTAND IT AND I AGREE TO BE BOUND BY IT. Signature of Parent/Guardian: Date: Printed Name: Printed Name of Child: {N0015230.1}